Dissociation: An insufficiently recognized major feature of complex posttraumatic stress disorder

Department of Clinical Psychology, Utrecht University, Utrecht, The Netherlands.
Journal of Traumatic Stress (Impact Factor: 2.72). 10/2005; 18(5):413-23. DOI: 10.1002/jts.20049
Source: PubMed

ABSTRACT The role of dissociation in (complex) posttraumatic stress disorder (PTSD) has been insufficiently recognized for at least two reasons: the view that dissociation is a peripheral, not a central feature of PTSD, and existing confusion regarding the nature of dissociation. In this conceptual article, the authors address both issues by postulating that traumatization essentially involves some degree of division or dissociation of psychobiological systems that constitute personality. One or more dissociative parts of the personality avoid traumatic memories and perform functions in daily life, while one or more other parts remain fixated in traumatic experiences and defensive actions. Dissociative parts manifest in negative and positive dissociative symptoms that should be distinguished from alterations of consciousness. Complex PTSD involves a more complex structural dissociation than simple PTSD.

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Available from: Onno van der Hart, Sep 28, 2015
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    • "For the treatment of complex PTSD, starting with stabilizing interventions prior to EMDR or prolonged exposure has been shown to improve the overall treatment effect (Cloitre et al., 2010; Dorrepaal et al., 2010, 2012). Assessment and treatment of dissociative disorders in traumatized groups is called for in light of the severe clinical condition of such patients and their low treatment success when dissociative disorders are not recognized (Boon & Draijer, 1993; Friedl & Draijer, 2000; Hart et al., 2005; Moskowitz, 2011; Read et al., 2005; Ross & Keyes, 2004; Sar et al., 2003). "
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    ABSTRACT: Interpersonal trauma exposure and trauma-related disorders in people with severe mental illness (SMI) are often not recognized in clinical practice. To substantiate the prevalence of interpersonal trauma exposure and trauma-related disorders in people with SMI. We conducted a systematic review of four databases (1980-2010) and then described and analysed 33 studies in terms of primary diagnosis and instruments used to measure trauma exposure and trauma-related disorders. Population-weighted mean prevalence rates in SMI were physical abuse 47% (range 25-72%), sexual abuse 37% (range 24-49%), and posttraumatic stress disorder (PTSD) 30% (range 20-47%). Compared to men, women showed a higher prevalence of sexual abuse in schizophrenia spectrum disorder, bipolar disorder, and mixed diagnosis groups labelled as having SMI. Prevalence rates of interpersonal trauma and trauma-related disorders were significantly higher in SMI than in the general population. Emotional abuse and neglect, physical neglect, complex PTSD, and dissociative disorders have been scarcely examined in SMI.
    European Journal of Psychotraumatology 04/2013; 4(4):19985. DOI:10.3402/ejpt.v4i0.19985 · 2.40 Impact Factor
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    • "A close relationship also exists between PTSD, dissociation , somatization, and a variety of other medical problems (see below). Some authors have argued that chronic interpersonal trauma, especially with childhood onset, such as incest, physical abuse, torture, or neglect, leads to a much broader range of symptoms, often with dissociative features, described as complex PTSD (C-PTSD) (Herman, 1992; Van der Kolk et al., 1996; Van der Hart et al., 2005; Cloitre et al., 2009). C-PTSD transcends current formulations of PTSD in three main areas of disturbance: (1) complex symptom presentations ; (2) characterological issues; and (3) vulnerability to repeated trauma. "
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    ABSTRACT: Three decades of posttraumatic stress disorder (PTSD) research have placed it well on the map. PTSD is a young disorder that started being properly understood only from 1980 with incorporation in DSM-III, in which it was acknowledged that exposure to traumatic events can lead to long-term psychopathology. This chapter reviews the history and nosology of the disorder, epidemiology, and etiology, as well as the clinical features. It lists the diagnostic assessments and provides an overview of the biological framework of the disorder by addressing brain, neurohormonal, and transmitter alterations. Exposure to traumatic events is commonplace. The majority of exposed subjects are resilient, as this is still the rule rather than the exception. The reported prevalence of PTSD is twice as common in females compared to males. The A criterion in PTSD expressed the traumatic event, after which the symptom clusters are based on intrusions, avoidance, and irritability. Gene-environmental studies are needed, with a focus on specific, distinct endophenotypes and influences from environmental factors (e.g., traumatic early-life experiences, with abuse or neglect, as well as exposure to disasters or combat). PTSD is often accompanied by comorbid disorders, such as depression and other anxiety disorders, as well as drug and alcohol abuse and dependence. The disorder is heterogeneous, sometimes with complex features that focus on emotional dysregulation, attachment, and dissociation. Several validated trauma assessments are available that allow quantification of trauma symptomatology. The biological framework is based on the concepts of stress sensitization and fear conditioning as well as failure of inhibition. After the decade of the hippocampus we have seen a shift to the decade of the amygdala in the new millennium. Given the specific role of the prefrontal cortex in (neuro)psychological functions in patients with PTSD (i.e., attention and cognitive interference), interest in the role of the prefrontal cortex will increase significantly. Increased multidisciplinary involvement, with inclusion of genetics, endocrinology, immunology, (neuro)psychology, and psychopathology, is essential to find consistency between biological, emotional, and cognitive dysfunction in PTSD. A variety of effective psychological and pharmacological interventions can be used to treat PTSD. The mechanisms of exposure therapy and cognitive therapy in influencing neurobiological markers need to be further investigated. The same goes for emerging therapies such as eye movement desensitization and reprocessing, virtual reality exposure, internet therapy, and neurofeedback. There are no specific drugs for PTSD, except for the treatment of irritability and depressive features with selective serotonin reuptake inhibitors. Other options, such as specific serotonergic agents, e.g., 5-HT(1A) antagonists, norepinephrine blockers, corticotropin-releasing factor antagonists, glucocorticoid receptor antagonists, prazosin and α(1)-adrenergic blocker with nightmares, and use of beta-blockers early after trauma exposure, are investigated. New treatment options such as d-cycloserine and cortisol seem to offer opportunities to influence memory consolidation of traumatic experiences in timed relation to exposure. For health economy it is important to be aware that there is an economic burden associated with PTSD, and treatments require the use of scarce resources. They will ultimately provide tools to ascertain the relative efficiency of different treatment options and plan the availability of these for the affected population. This can be seen as the biggest challenge for the future evolution of the disorder.
    Handbook of Clinical Neurology 01/2012; 106:291-342. DOI:10.1016/B978-0-444-52002-9.00018-8
    • "Given these and other study findings, dissociation must be understood as both dimensional (absorption and imaginative involvement) and as a typological construct indicating pathological dissociation (amnesia for dissociative states, derealization, depersonalization and identity alterations ) (Waller, Carlson, & Putnam, 1996). Under extreme stress, peritraumatic dissociative responses offer momentary psychological protection and include a subjective sense of numbing, detachment, absence of emotional responsiveness, feeling dazed and disoriented, inability to remember parts of a traumatic event, feeling outside of your body, feeling that the world is too intense or dull or feeling as if you are in a daze (APA, 2000; Nijenhuis, van Enyen, Kusters, & van der Hart, 2001; van der Hart et al., 2005). These transient peritraumatic dissociative responses support our ability to focus on the immediate situation while delaying emotional and cognitive flooding that may hamper survival behavior. "
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    ABSTRACT: The prevalence of pathological and nonpathological dissociation (as defined in the DSM-IV) was assessed in two elite populations, international rhythmic gymnasts (RGs) from the Bulgarian and US National Rhythmic Gymnastics Teams and professional concert dancers from Bulgaria, Canada and United States. The Dissociative Experience Scale–II was used to measure type and frequency of dissociation. Dissociative tendencies among RGs and dancers were similar, and different from controls. Dancers endorsed significantly more experiences of feeling their body did not belong to them. RGs had significantly greater ability to ignore pain and claimed increased experiences of ease when performing difficult tasks. Individuals from the two elite populations, and not the control group, scored in the pathological range for dissociative disorders. The results confirmed the need for further clarification of degree and severity of dissociation among elite populations; populations that place very high demands on their body and hold high expectations for success.
    International Journal of Sport and Exercise Psychology 09/2011; 9(3-3):238-250. DOI:10.1080/1612197X.2011.614850
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